Medical Reviewer Iii (Medicare/Drg)

Empower AI is seeking a Medical Review Specialist III (Medicare DRG) to perform comprehensive medical record and claims review for Medicare DRG claims, supporting healthcare reform initiatives at a national level.

Location: United States

Responsibilities

• Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare DRG.
• Performs first level of Medical Review in determination of claims payment review.
• Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles.
• Utilize electronic health information imaging and input medical review decisions by electronic database module.
• Utilize internet and intranet sources for policy verification.
• Utilize Microsoft Office suite and other software templates as associated source input for claims review.
• Make clinical judgment decisions based on clinical experience when applicable.
• Responsible for review of Medicare DRG claims.
• Meeting quality and production standards.
• Ensuring departmental compliance with quality managements system and ISO requirements.
• Completes other projects or duties assigned by the Medical Review Lead Specialist.

Requirements

• Must be a Registered Nurse obtained by either a Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.
• At least four (4) years claims knowledge either from billing, reviewing, or processing of Durable Medical Equipment.
• At least three (3) years clinical experience as a Registered Nurse.
• Minimum two (2) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Physician Office practices, Laboratory, and Ambulance Services.
• Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
• Ability to keep sensitive and confidential material private.
• Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program and must have no conflict of interest (COI).